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Suggested Citation:"3 New Models of Care." Institute of Medicine. 2008. Retooling for an Aging America: Building the Health Care Workforce. Washington, DC: The National Academies Press. doi: 10.17226/12089.
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Below is the uncorrected machine-read text of this chapter, intended to provide our own search engines and external engines with highly rich, chapter-representative searchable text of each book. Because it is UNCORRECTED material, please consider the following text as a useful but insufficient proxy for the authoritative book pages.

3 New Models of Care CHAPTER SUMMARY This chapter presents the committee’s vision for the care of older adults in the future and describes a number of new models of care delivery that show promise for achieving this vision. Widespread implementation of new models of care will require changes in traditional staffing patterns and provider roles. Despite the evidence that patient care can be improved through the implementation of new models of care, diffusion of those models has been limited, in part due to external constraints such as insuf- ficient funding. The committee recommends improved dissemination of models that have been shown to be effective as well as increased support for research and demonstration programs that promote the development of new models of care. The nation faces major challenges as it prepares for the growing num- ber of older adults. There is a pressing need to develop a health care work- force that is sufficient in size and ability to meet the needs of this group. Projections indicate that there will be significant workforce shortfalls in the coming years, but simply increasing the numbers of geriatric-trained work- ers will not be sufficient, as it will do nothing to fix the deficiencies in the way care is delivered to older adults or to address the inefficiencies in the current system. The care that is currently provided to older adults often falls short of acceptable levels of quality. Providers’ performance in the delivery of recommended care to older adults varies greatly (RAND, 2004), and there is limited coordination of care among providers. Expanding the ca- pacity of the current system to meet the future needs of older adults would 75

76 RETOOLING FOR AN AGING AMERICA be a wasted opportunity. Instead, the current care delivery system requires significant reform in order to improve the care of this population. This chapter begins with the committee’s vision of how best to deliver health services to older adults in the future. The vision represents a major departure from the current system, and its implementation will require shifts in the way that services are organized, financed, and delivered. After this vision has been detailed, the chapter continues with a discussion of models of health care delivery that hold promise for moving closer toward the committee’s vision. The chapter examines the evidence on several mod- els as well as the challenges that will likely be encountered in disseminating these models. Although better models can lead to better care, dissemination of improved models has generally proved to be limited, in part due to finan- cial disincentives to implementing these better models. Thus the committee offers its recommendation for how to foster dissemination of new models. Finally, the chapter discusses shifts in the workforce that may be required to support these new models, such as new roles for providers, increased delegation of responsibilities, greater use of interdisciplinary teams, and increased involvement of patients and their families. A VISION FOR CARE IN THE FUTURE The committee identified three key principles that need to form the basis of an improved system of care delivery for older Americans (Box 3-1). These principles are in alignment with the six aims of quality defined in Crossing the Quality Chasm (IOM, 2001). First and foremost, the health needs of the older population need to be comprehensively addressed, and care needs to be patient-centered. For most older adults care needs to include preventive services (including life- style modification) and coordinated treatment of chronic and acute health conditions. For frail older adults social services may also be needed in order to maintain or improve health. These social services need to be integrated with health care services in their delivery and financing. Furthermore, ef- BOX 3-1 Principles of Care • The health needs of the older population need to be addressed comprehensively. • Services need to be provided efficiently. • Older persons need to be active partners in their own care.

NEW MODELS OF CARE 77 forts need to be made to reduce the wide variation in practice protocols among providers, which should further enhance the quality of care for older adults. The principle of comprehensive care also includes taking into account the increasing socio-demographic diversity of older adults. The number and percent of ethnic minorities in the older population is increasing dramati- cally, and even within ethnic groups there is tremendous cultural diversity. Health care providers need to be sensitive to the wide variety of languages, cultures, and health beliefs among older adults. Other segments of the older population face additional challenges. For example, older adults in rural areas often face isolation and barriers to access for some services. The second principle underlying the vision of care in the future is that services need to be provided efficiently. Providers will need to be trained to work in interdisciplinary teams, and financing and delivery systems need to support this interdisciplinary approach. Care needs to be seamless across various care delivery sites, and all clinicians need to have access to patients’ health information, as well as population data, when needed. Health infor- mation technology, such as interoperable electronic health records and re- mote monitoring, needs to be used to support the health care workforce by improving communication among providers and their patients, building a record of population data, promoting interdisciplinary patient care and care coordination, facilitating patient transitions, and improving quality and safety overall. Giving providers immediate access to patient information, especially for patients who are cognitively impaired and unable to provide their own clinical history, may reduce the likelihood of errors, lower costs, and increase efficiency in care delivery. Efficiency can be further improved by ensuring that health care person- nel are used in a way that makes the most of their capabilities. Expanding the scope of practice or responsibility for providers has the potential to increase the overall productivity of the workforce and at the same time promote retention by providing greater opportunities for specialization (e.g., through career lattices) and professional advancement. Specifically, this would involve a cascading of responsibilities, giving additional duties to personnel with more limited training in order to increase the amount of time that more highly trained personnel have to carry out the work that they alone are able to perform. While the necessary regulatory changes would likely be controversial in some cases, the projected shortfall in workforce supply requires an urgent response. This response will most likely have to involve expansions in the scope of practice at all levels, while at the same time ensuring that these changes are consistent with high-quality care. The third principle is that older persons need to be active partners in their own care, except when they are too frail, mentally or physically, to do so. Such partnerships need to include the adoption of healthy lifestyles,

78 RETOOLING FOR AN AGING AMERICA self-management of chronic conditions, and increased participation by the patient in decision making. By becoming participants in their own care, pa- tients can improve their health, reduce unnecessary treatments, and reduce the need for reliance on formal or informal caregivers. Putting this vision into effect will require changes in policy and a re- structuring of the health care financing and delivery systems. The purposes of this chapter are to highlight those models of care delivery that hold promise for providing high-quality and cost-effective care for older adults and for promoting the committee’s vision for the future of care delivery; to discuss the dissemination of new models of care; and to explore the changes to the workforce that would best support those models. NEW MODELS OF CARE DELIVERY A number of new models of care have been developed with the aim of improving quality and patient outcomes, promoting cost savings, or both. The proliferation of these new models indicates not only a recognition that services for older adults need to be improved but also a willingness among providers, private foundations, and federal and state policy makers to com- mit resources to learning about better ways to finance and deliver care. Nonetheless, while it is widely accepted that the current way of car- ing for older adults can be improved, there is little guidance available to provider organizations about which interventions are most effective. Ob- taining information on the effectiveness of various models is challenging for two reasons. First, a general information gap exists. Many promising approaches have not yet generated reliable or complete findings, and some may never undergo rigorous evaluation because the resources required to systematically collect data on a program can be prohibitive. Second, evalu- ations often come up with conflicting results. Many models have elements in common (e.g., interdisciplinary teams, care coordination, disease man- agement), and some evaluations of particular elements may indicate success while others find no effect. It can be difficult to explain such discrepancies because evaluations rarely provide information about key inputs, such as staffing and training, or about the effects that these inputs have on program outcomes. In order to obtain a better understanding of the models that hold the most promise, the committee commissioned a paper to identify those ap- proaches to comprehensive health care delivery for older adults that have the strongest evidence base. The review focused on frail older persons and was limited to models that have been shown, in high-quality controlled trials, to produce significant improvements in quality or efficiency (i.e., uti- lization and cost). The threshold for inclusion was the existence of one meta- analysis or at least three randomized controlled trials or quasi-experimental

NEW MODELS OF CARE 79 studies showing positive results. Undoubtedly these constraints led to the exclusion of a number of approaches that may actually show promise in the future, but a full analysis of every approach ever devised is beyond the scope of this report. The scope of the review was limited to articles published between January 1987 and May 2007 on care models that were staffed primarily by health care professionals and that in some way involved comprehensive care (that is, were related to treatment for several chronic conditions, to treatment for several aspects of one condition, or to treatment from mul- tiple providers). Altogether, the authors of the commissioned paper reviewed 128 ar- ticles reporting positive results. Because the number of new models of care that have been developed is so large, it is not possible to discuss each one. The models of care described here offer a few examples of the innovative ways in which care is being provided to older adults at several points along the care continuum and in a variety of settings. Notably, many of the mod- els strive to provide care in a manner that is consistent with the committee’s vision—in a more comprehensive way (e.g., by providing services beyond those normally available), more efficiently (e.g., through the coordination of medical and social services and the shifting of traditional provider re- sponsibilities), and with encouragement for older adults to take on more active roles in their own care. Private-Sector Models Improving Mood: Promoting Access to Collaborative Treatment for Late Life Depression (IMPACT) Depression in older adults is common, particularly among individu- als with chronic illness (Katon, 2003). Because of the importance of this disease to the older adult population, the John A. Hartford Foundation as- sembled a panel of national experts to design a program to treat depression in the primary care setting. The result was the IMPACT program, a care model that builds upon evidence-based treatment for depression and that incorporates approaches used in managing other chronic diseases, such as diabetes. Those approaches include collaboration among patients, primary care providers, and specialists (including the use of targeted consultations); development of a personalized treatment plan; proactive follow-up and monitoring; and protocols for stepped care (Unutzer et al., 2002). Patients participating in IMPACT receive educational materials about late-life depression and visit a depression-care manager at a primary care clinic. The care managers (typically nurses, psychologists, and social work- ers) are trained as depression clinical specialists and work with the patient’s

80 RETOOLING FOR AN AGING AMERICA regular primary care provider to establish a treatment plan. These care man- agers are supervised by a team psychiatrist and a primary care physician. Under the IMPACT program, the care managers monitor patients in person or by telephone and have contact with each patient at least once every other week. They encourage patients to engage in social events, and they refer them for additional health or social services as necessary. If a pa- tient recovers from depression, a relapse-prevention plan is developed, and the care manager continues to follow up with the patient. If a patient does not respond to treatment, the patient’s case is discussed by the IMPACT team, the patient receives a consultation with a psychiatrist at the primary care clinic, and the patient’s medications may be altered. The IMPACT program has reported successes according to a vari- ety of measures. Participants had higher rates of depression treatment, for example, and greater reductions in depressive symptoms compared to nonparticipants (Unutzer et al., 2002). Participants were also more satis- fied with their care and reported less functional impairment and greater quality of life. They experienced an average of 107 more depression-free days over a 2-year period than did patients receiving usual care (Katon et al., 2005). Positive results also held over time. One year after IMPACT activities ended, participants maintained improvements with respect to antidepressant treatment, depressive symptoms, remission of depression, physical functioning, quality of life, self efficacy, and satisfaction with care as compared with a control group (Hunkeler et al., 2006). Results from the model indicate that evidence-based care for major depression can be successfully delivered by specially trained nurses, psy- chologists, and social workers in primary care settings. Total outpatient costs were $295 higher for participants during the course of the program, or an average of $2.76 for each additional depression-free day. Another evaluation of IMPACT, limited to older adults with depression and dia- betes, found that the incremental outpatient cost for each depression-free day was 25 cents (Katon et al., 2006). It is difficult to know, however, the degree of cost savings that may have been realized through the prevention of unnecessary hospitalizations or other treatments associated with unman- aged depression. Geriatric Resources for Assessment and Care of Elders (GRACE) Providing health care for low-income older adults is challenging for a number of reasons, including their high incidence of chronic illness, limited access to care, low health literacy, and socioeconomic stressors (Counsell et al., 2007). To improve the care provided to these patients, the GRACE model was developed by researchers from the Indiana University School of Medicine, the Indiana University Center for Aging Research, and the

NEW MODELS OF CARE 81 Regenstrief Institute. The GRACE intervention provides home-based, in- tegrated geriatric care by a team consisting of a nurse practitioner and a social worker that visits patients at their homes for an initial assessment and then follows up with the patients at least once a month, either by phone or face to face. The team also visits the patients at home after any emergency-department or hospital visit. This two-person team is supported by a larger interdisciplinary team which is led by a geriatrician and which also includes a pharmacist, physical therapist, mental health social worker, and community-based services liaison. This group, using input from the patient’s primary care physician, establishes a care plan for the patient which incorporates protocols that have been developed for the treatment of 12 targeted geriatric conditions. The GRACE interdisciplinary team meets weekly to discuss the patient’s progress with the smaller team. The team’s efforts are also supported by an electronic medical record and web-based tracking system. In a controlled clinical trial, Counsell and colleagues found that the GRACE program resulted in improved quality of care and reduced acute- care utilization among a group of high-risk, low-income seniors. However, improvements in health-related quality of life were mixed, and physical functional outcomes did not differ from the control group (Counsell et al., 2007). These somewhat mixed results may be explained by several factors, including the difficulty of quantifying the comprehensiveness, coordination, and patient-centeredness of the care. Furthermore, the study duration may have been too short to allow a complete assessment of the intervention (Reuben, 2007). The Green House Model Historically, residents’ quality of life in nursing homes has received insufficient attention (Bowers, 2006). For example, nursing home residents often have little choice in their schedules or daily activities. Over the past decade, however, a small but growing movement has developed whose goal is to change the culture of traditional nursing-home care both to im- prove workers’ job satisfaction and to improve the residents’ quality of life through transformed environments, greater choice, and more empowerment of the direct-care staff. Several new models of nursing-home care have been developed that move away from a medical model of care toward a more patient-centered approach. One such model is the Green House (GH), which is designed to make residents feel at home (March, 2007). The GH model emphasizes residents living their lives under normal, rather than therapeutic, circumstances. The model was based on the principles of the Eden Alternative, a movement to foster culture change within nursing homes by creating a home-like culture

82 RETOOLING FOR AN AGING AMERICA with plants, pets, and visits by children (Hamilton and Tesh, 2002). The Eden Alternative also decentralizes the organizational structure of nursing homes to empower certified nursing assistants (CNAs) to develop their own schedules and daily assignments and to provide companionship to the residents. GHs take the concept one step further by creating a more residential social setting. The initial development and implementation of the GH model was sup- ported by grants from private foundations. The model involves three key elements. First, the environment is composed of a small, technologically sophisticated house that functions as a home for eight to ten residents. Each resident has a private room and bathroom, and the residents’ individual rooms are clustered around a central area with a shared kitchen, dining room, and living room. GHs serve as real homes in appearance and func- tion and, as such, do not have nurses’ stations, medication carts, or public address systems (Kane et al., 2007). Second, the frontline caregivers have broad roles that include personal care, cooking, housekeeping, and assuring that residents spend time accord- ing to their preferences. These direct-care workers, referred to as shahbazim, receive 120 hours of training above those required to be a CNA. This level of training is significantly beyond federal and state requirements and reflects the CNAs’ expanded role in a GH. In addition, there are “sages,” older adults who serve as coaches or mentors to the shahbazim, and “guides,” who are supervisors and serve as liaisons between the shahbazim and other staff. This system of support is the basis of the care team. Third, professional healthcare providers (e.g., nurses, physicians, social workers, and pharmacists) form visiting clinical support teams that provide specialized assessments for residents. Licensed nurses are available and responsible for the clinical care in the GH. A nurse is available to shahba- zim whenever needed, 24 hours a day, by emergency pager (NCB Capital Impact, 2007). While information on the effectiveness of GHs is preliminary, a recent evaluation of the model showed that GH residents reported better quality of life on several measures, higher satisfaction with their place of residence, and better emotional health than a comparison group (Kane et al., 2007). No difference in self-reported health was noted. Quality of care was at least as good in the GH group as in the control group. The GH group also had a lower prevalence of residents on bed rest, fewer residents with limited activity, and a lower prevalence of depression compared with residents of traditional nursing homes. In addition to its potential to promote patient-centered care, the GH model also holds promise for improved recruitment of direct-care workers. The first GH site received only two responses to advertisements for a CNA but received more than 70 when the ad was for a shahbaz (Angelelli, 2006).

NEW MODELS OF CARE 83 Shahbazim are paid approximately 10 percent more than CNAs for their additional responsibilities and training hours (NCB Capital Impact, 2007). The additional pay is made possible through stabilization of the direct-care workforce (i.e., lower costs due to decreased turnover rates), operational efficiencies, and diminished need for middle-management positions. How- ever, GHs do require providers to adapt to new roles. For example, attend- ing physicians and medical directors provide care in disaggregated homes where shahbazim are central to the care of residents and are responsible for monitoring their status based on the direction of physicians (Kane et al., 2007). This is different from the situation in the typical nursing home setting, where physicians have traditionally had little communication with direct-care staff. The Advanced Illness Management (AIM) Program Numerous studies have shown deficiencies in the quality of care at the end of life. Many older adults die with inadequate palliative care (Zerzan et al., 2000), and often patient preferences are not assessed, communicated, or followed (Haidet et al., 1998; Hofmann et al., 1997). Most patients prefer to die at home, yet most deaths occur in the hospital (Brumley et al., 2007; Grande et al., 1999). And although hospice care can lead to higher patient and family satisfaction at a lower cost (Brumley et al., 2007), many individuals do not receive hospice care (NHPCO, 2005), and those who do receive it rarely use the full Medicare hospice benefits (Ciemins et al., 2006). In an effort to bridge the gap between curative care and hospice care, Sutter Visiting Nurse Association and Hospice created the Advanced Illness Management (AIM) program, which provides both disease-modifying care and comfort care in the home setting to those with advanced illnesses who are eligible for home care but not yet eligible for hospice care (Ciemins et al., 2006). Patients are included regardless of Medicare eligibility or insur- ance coverage. The program coordinates hospital services, home health care, and, when needed, hospice services. The goals of the program are to provide seriously ill patients with an array of home-based services, to ease their transition from home health care to hospice care, and to avoid un- necessary hospitalizations. The program uses a combination of home care and hospice staff. Nurse case managers (known as AIM nurses) are the primary providers for AIM patients. They educate patients on disease process and prognosis, treat- ment alternatives, advance care planning, avoidance of unnecessary hos- pitalization, management of pain and symptoms, and hospice enrollment. Additionally, AIM nurses receive training classes that cover such topics as palliative care definition and philosophy, insurance coverage, home care

84 RETOOLING FOR AN AGING AMERICA and hospice regulations, and facilitating difficult conversations. They also attend biweekly patient-centered conferences. An early evaluation of the program found that AIM program patients had higher rates of hospice utilization (Ciemins et al., 2006). Notably, the program was successful in increasing hospice utilization by African Ameri- cans, a group that has traditionally had very low rates of hospice use. Medicare Research and Demonstration Projects In addition to private-sector initiatives, a number of models have been tested by the Centers for Medicare and Medicaid Services (CMS). These demonstration projects have examined mechanisms to restructure the Medi- care and Medicaid programs in ways that support more efficient and more effective care delivery for older adults. For example, older adults with long-term health care needs often face fragmentation in their care because the Medicare program finances acute care at the national level while state- administered Medicaid programs are the predominant payers for long-term care services (Kaiser Family Foundation, 2006). Discontinuities between the two programs can translate into discontinuities in care as well as into higher costs, as the two programs often seek to shift costs to each other (National Commission for Quality Long Term Care, 2006). CMS demonstration projects have tested a number of ways to improve quality in Medicare (and often Medicaid as well). Several of these projects are described below. Programs of All-Inclusive Care for the Elderly (PACE) PACE is a managed-care program that was developed to address the spectrum of needs for adults aged 55 and older with disability levels that make them eligible for nursing-home care (Tritz, 2005). The program is based on the belief that the well-being of older adults can be improved by serving them in the community (Mukamel et al., 2007). PACE was modeled after an innovative initiative in San Francisco, On Lok, that was designed to help the Asian American community care for older adults in their homes (Greenwood, 2001). Start-up funds for PACE were provided by private foundations, and its implementation was supported by congressional authorization of Medicare and Medicaid waivers (Gross et al., 2004). The PACE model funds a com- prehensive set of services by combining federal Medicare dollars, state and federal Medicaid funds, and the individuals’ own contributions (National PACE Association, 2007). The PACE service package includes all Medicare and Medicaid covered services plus additional services, including adult day care, nutritional counseling, recreational therapy, transportation, and personal-care services, such as meals at home (CMS, 2005). PACE also pays for nursing-home care, if appropriate.

NEW MODELS OF CARE 85 PACE services are provided by an interdisciplinary team composed of at least the following members: a primary care physician, a registered nurse, a social worker, a physical therapist, a pharmacist, an occupational therapist, a recreational therapist, a dietician, a PACE center manager, a home-care coordinator, personal-care attendants, and drivers (Mukamel et al., 2007). The team approach in PACE is innovative in its inclusion of both profes- sionals and direct-care workers as part of the care team. Each member of the team performs an initial assessment of each patient, and then the group works together to create a single care plan that takes the different assess- ments into account. The team holds weekly care-planning meetings during which the care plans are reassessed. The services, which are provided primarily at an adult day-care center, are also highly coordinated (Cooper and Fishman, 2003; Mukamel et al., 2006). The center includes a health clinic and at least one common room for social and recreational activities. PACE enrollees attend the day center approximately three days per week, enabling team members to identify subtle changes in health status or mood and to address them quickly. Team members regularly reassess the medical, functional and psychosocial condi- tions of patients and document any changes in the medical record. An evaluation of the PACE demonstration program found that enroll- ment was associated with higher patient satisfaction, improved health status and physical functioning, an increased number of days in the community, improved quality of life, and lower mortality (Chatterji et al., 1998). The benefits of PACE were even greater for the frailest older adults, whose en- rollment was associated with lower rates of service utilization in hospitals and nursing homes and higher rates of ambulatory care services. An analysis showed that capitated payments under PACE were about 10 percent higher than the payments that would have been likely under the fee-for-service (FFS) program. The analysis found savings for Medi- care but higher costs for Medicaid. Capitated Medicare payments were 42 percent lower than projected Medicare FFS expenditures, but capitated Medicaid payments were 86 percent higher than projected FFS expenditures (Grabowski, 2006; White et al., 2000). It is also notable that PACE programs have achieved some success in the recruitment of direct-care workers (Hansen, 2007). The program has a 12 percent annual turnover rate among aides, well below rates reported nationally. Aides at PACE sites are given opportunities for career advance- ment, and PACE provides financial support to direct-care workers seeking additional training. Evercare The Evercare program, originally developed by United Health Care Corporation, assigns nursing-home residents to a risk-bearing health main-

86 RETOOLING FOR AN AGING AMERICA tenance organization (HMO) (Inglis et al., 2004) that coordinates Medicare acute-care services and nursing-home services under Medicaid (Hansen, 2007). Under the program, nurse practitioners provide more intensive primary care services than is typical for nursing-homes residents, and they coordinate enrollees’ care with the nursing-home staff (Stone, 2000). The nurse practitioners have relatively small caseloads and visit each of the nursing homes every second or third day. They are engaged in clinical work, spending about one-third of their days on direct patient care, and they also serve in a coordinating role, communicating information to various par- ties, including nursing-home staff, families, and patients’ physicians. The nurse practitioners work with nursing-home staff to monitor treatment and to identify changes in patient status. The Evercare program also educates nursing-home staff through formal in-service training as well as through less formal on-the-job training. An evaluation of the Evercare program showed that it succeeded in reducing hospital admissions and in providing high-quality coordinated care to patients, with a number of caveats (Kane et al., 2002). The analysis showed that, on average, the use of nurse practitioners saved approximately $88,000 per year per nurse practitioner in reduced hospital usage. In large part this reduction in hospital usage resulted from Evercare’s use of inten- sive service days, through which nursing homes were paid an extra fee to take on cases that might otherwise be handled in the hospital. The evalua- tion concluded that providing more intensive primary care to nursing-home residents produced more efficient crisis care, but it typically did not pre- vent the crises themselves. In addition, the capitated payments resulted in overpayment to the plan and no Medicare cost savings (Kane et al., 2002). Nonetheless, the Medicare Modernization Act (MMA) of 2003 made the Evercare program a permanent option. Social HMO Demonstrations The Social HMO (SHMO) demonstrations focused on new approaches for providing care on a capitated basis to patients with complex medi- cal needs, specifically frail patients at risk for nursing-home placement (Vladeck, 1996). The Deficit Reduction Act of 1984 called for a demon- stration of the SHMO concept (SHMO I), which sought to integrate health care services and long-term care services. A second demonstration model (SHMO II) was authorized in the Omnibus Budget Reconciliation Act of   Medicare Modernization Act of 2003. Public Law 108-173. 108th Congress. (2003).   Deficit Reduction Act of 1984. Public Law 98-369. 98th Congress. (1984).

NEW MODELS OF CARE 87 1990. Four sites became operational under SHMO I, and only one plan participated in SHMO II (Thompson, 2002). Enrollees of the SHMOs received coordinated acute-care and community- care benefits, including personal care, homemaking services, adult day care, personal emergency response service, transportation, respite, durable medical equipment, and short-term institutional care for convalescent and respite stays (Leutz and Capitman, 2005). Integration of acute care and long-term care involved operational linkages, including referral systems, as well as sharing of assessments and clinical data, management of transitions across settings, and benefit coordination. The project did not generally involve such strategies as changing the practice patterns of primary care physicians to include geriatric principles or the hiring of a variety of geriatric practi- tioners. The SHMO II model incorporated a more team-oriented geriatric approach to care than did the first demonstration, and it brought together primary care physicians, geriatricians, specialists, pharmacists, dieticians, and nurse case managers (Thompson, 2002). Project evaluations for SHMO I generally found the effects of the pro- gram to be limited in terms of cost and enrollee outcomes, although the methodologies employed by these analyses have been criticized (Atkinson, 2001; Manton et al., 1993). A study by Manton and colleagues found that SHMOs produced better outcomes for healthy and acutely ill enrollees than for impaired persons or for acutely ill persons with chronic impairments (Manton et al., 1993). The same report found that neither the long-term care services provided by the SHMOs nor their integration with acute care appeared to be effective. An evaluation conducted for CMS in 2002 found that payments to SHMOs were 15 percent to 30 percent higher than stan- dard HMOs would have received for the same enrollees (Thompson, 2002). Another study, however, found that the termination of the Minneapolis SHMO project in 1994 was associated with a 40 percent increase in long- term institutional placement, indicating that the program had been effective in its primary objective of keeping older adults in community-based settings (Fischer et al., 2003). Other Medicare Demonstrations In addition to the demonstration projects described above, the Medi- care program has developed and implemented a number of other dem- onstration projects that have tested new ways of delivering care to older adults. CMS’s demonstration authority allows the agency to waive certain rules concerning which services are covered and how they are reimbursed in   Omnibus Budget Reconciliation Act of 1990. Public Law 101-508. 101st Congress. (1990).

88 RETOOLING FOR AN AGING AMERICA order for the agency to be able to test and measure the effects of potential program changes (Thompson, 2002). Table 3-1 offers details on several of the demonstration projects. These demonstrations were designed to encourage coordinated care for chroni- cally ill beneficiaries and to address some of the structural impediments to providing appropriate care for these beneficiaries. The designs of many of the projects were based on disease-management programs developed in the private sector (CMS, 2007b). The hope was that the demonstration projects would point to ways to improve treatment plans, reduce avoidable admis- sions, and promote improved patient outcomes without increasing cost. Unfortunately, the majority of these demonstration projects had little effect on patient outcomes and produced no cost savings. In fact, in a number of cases Medicare expenditures increased as a result of the project, in part be- cause of expansion of services and in part because the specific savings that had been projected were not realized. As discussed previously, the mixture of results makes it difficult to pinpoint which elements of these models are most likely to lead to successful improvements in patient care. The evaluations revealed that the demonstration projects encountered a number of difficulties, including problems enrolling patients in the dem- onstrations, low levels of enthusiasm for the program by patients and physicians, inexperienced or inadequately trained staff, and hardware and software problems with patient-monitoring equipment (Guterman, 2007). Still, considering the evidence that the Medicare program often falls short on various dimensions of quality and efficiency, the need to research and develop alternative approaches to care delivery remains paramount. Despite this need, however, relatively little investment has been made in the research and development of innovative models of care that could improve outcomes or lower costs, particularly as compared with how much is spent each year on the health care of older adults. In fiscal year 2007, for example, the total budget for Medicare operations was more than $2 billion; less than 2 percent of this was spent on research, demonstration, and evaluation (Table 3-2). In fact, in recent years Medicare has spent a decreasing proportion of its operations budget on research, demonstration, and evaluation. This low investment is even more startling when compared to the hundreds of billions of dollars spent on Medicare benefits. In order to improve the way that care is delivered, more investments will be needed to explore newer and more efficient models of care. Medicaid Demonstration Projects Many state Medicaid programs have developed innovative models of care to integrate services, to improve care coordination, and most notably, to allow individuals a larger role in shaping the services that they receive. In

NEW MODELS OF CARE 89 TABLE 3-1  Findings from Select Medicare Demonstration Projects Project (Start Year) Purpose Outcomes Care Management To study various care- Ongoing. Will review 3-year pilot for High Cost management models for programs implemented by six Care Beneficiaries (2005) high-cost beneficiaries in the Management Organizations (CMOs). traditional Medicare fee-for- service program who have one or more chronic diseases (e.g., Texas Senior Trails; Health Buddy). Community Tested the use of nurse case Enrollment did not affect health status Nursing managers to coordinate care or utilization of services covered Organization and provide enrollees with under the traditional Medicare benefit Demonstration a more flexible array of package. Total expenditures for (2003) services, such as prevention treatment groups were significantly and health promotion, under greater than the control group. a capitated arrangement. Medicare Disease To evaluate the effect of The three demonstration sites Management disease-management services, encountered difficulties identifying and Demonstration coupled with a prescription enrolling beneficiaries, and, given the (2003) drug benefit, for those with magnitude of the risk they faced, the advanced-stage congestive project was discontinued prior to the heart failure, diabetes, or intended conclusion date. coronary disease. Medicare To test whether providing Interim evaluation found increases in Coordinated Care coordinated-care services to beneficiary education but no effect on Demonstration Medicare beneficiaries with satisfaction, patient adherence, self (2001) complex chronic conditions care, or Medicare expenditures. There can yield better patient was a small but statistically significant outcomes without increasing reduction in the proportion of patients program costs. hospitalized during the year after enrollment. Informatics for To test the use of Interim evaluation shows the project Diabetes Education telemedicine networks had favorable effects on diabetes and Telemedicine to improve primary and control and care, use of recommended (IDEAtel) (2000) preventive care for Medicare medications, and communication beneficiaries with diabetes with health care providers about diet who live in underserved and care. The demonstration did not inner-city and rural areas of generate savings to the Medicare New York. program and was costly to implement ($8,200 to $8,900 per enrollee per year). Medicare Case To provide case-management Despite high levels of satisfaction Management (Early services to beneficiaries with among the beneficiaries who Coordinated Care) catastrophic illnesses and participated, there was no Demonstrations high medical costs. improvement in self care or health. (1995) Medicare spending was not reduced. SOURCE: CMS, 2008a.

90 RETOOLING FOR AN AGING AMERICA TABLE 3-2  Appropriations History of Medicare Research, Demonstration, and Evaluation as Compared to Medicare Operations Research, Total Medicare Research, Demonstration, Fiscal Demonstration, and Operations and Evaluation as Percent Year Evaluation (in Millions) (in Millions) of Medicare Operations 2003 $73.7 $1,666.7 4.42% 2004 $77.8 $1,701.0 4.57% 2005 $77.5 $1,730.9 4.48% 2006 $69.4a $2,200.8b 3.15% 2007 $41.5 $2,210.6c 1.88% 2008d $33.7 $2,303.6 1.46% aIncludes Deficit Reduction Act funding. bIncludes Deficit Reduction Act and the Secretary’s Section 202 Transfer Authority funding. cIncludes Tax Relief and Health Care Act of 2006 funding. d2008 reflects the President’s FY 2008 budget. SOURCE: DHHS, 2007. Maine, for example, Medicaid beneficiaries are referred to a consumer-run independent living center, which assesses their preferences and their ability to self-direct care, trains them with regard to hiring and managing their own services, and provides a list of available workers (Benjamin, 2001). Oregon’s Medicaid program allows individuals, with guidance from case managers, to hire and fire workers as they choose. An evaluation of these models found that patients had greater satisfaction with services, increased feelings of empowerment, and better perceived quality of life (Stone, 2000). There is limited evidence, however, that focuses specifically on older adults and the effect that these programs have on them. Four of these programs are described below. Arizona Long-Term Care System (Arizona) The Arizona Long-Term Care System (ALTCS) was developed in 1989 to provide care to Medicaid-eligible individuals who are at risk of institu- tionalization in a long-term care setting, typically older adults and disabled persons. ALTCS is a capitated, mandatory long-term care system in which services are integrated by a managed care organization into a single deliv- ery package. For those beneficiaries also eligible for Medicare, providers must bill those services to Medicare and are paid through the FFS system. Services offered under ALTCS include acute medical care, behavioral health services, and case management. Services are also covered for care delivered in nursing homes, in the home setting, and in assisted-living facilities.

NEW MODELS OF CARE 91 ALTCS pays for part of the costs for room and board, medical and hospital care, and prescription drugs. An evaluation of ALTCS showed that, compared to New Mexico Med- icaid (a traditional Medicaid program), ALTCS provided quality care at lower costs (McCall, 1997). Program savings averaged 18 percent annually, totaling $290 million in savings for medical services alone. ALTCS benefi- ciaries had more medical visits but fewer hospital days than beneficiaries of New Mexico Medicaid. During the first 13 years of the program, however, the quality of care was found to be higher in the traditional Medicaid pro- gram. This program is still active in Arizona. Senior Health Options (Minnesota) The Minnesota Senior Health Options (SHO) program was adopted with support from the Robert Wood Johnson Foundation. SHO offers en- rollees a package of acute and long-term care services through a choice of managed care plans. The state is essentially treated like a health plan that contracts with CMS to provide services; the state then subcontracts with health plans that combine services from Medicare and Medicaid into one integrated benefit package for enrollees (CMS, 2004; Malone et al., 2004). At the center of the initiative is coordination of care for dually eligible beneficiaries who live in institutions or who live in the community but meet institutional placement criteria. Evaluations indicate that enrollees in the program had fewer hospitalizations and emergency room visits (Kane et al., 2004) and were more likely to receive preventive services (Kane and Homyak, 2003); however, capitation rates were higher than they would be under fee-for-service. The program, which began in 1997, continues to operate and became a statewide option in 2005 (Tritz, 2006). Family Care (Wisconsin) The goals of Wisconsin’s Family Care program are to improve patient choices regarding type of residence and service supports that enrollees receive, improve access to services and quality of care, and achieve cost ef- ficiencies (Justice, 2003). The program has two significant design features: a single entry point for patients (an Aging and Disability Resource Center) and patient-centered services. The center provides patients with advice and access to long-term support options, screening to determine eligibility for publicly financed services, and pre-admission consultations for those enter- ing nursing homes or residential care facilities. The centers are staffed by social workers and nurses who are supported by direct-care workers and volunteers. Together these workers conduct a comprehensive assessment of patients’ needs, preferences, and values.

92 RETOOLING FOR AN AGING AMERICA Care-management organizations (CMOs) manage the Family Care benefits, providing services in community, residential, and institutional settings (Justice, 2003). Funding from multiple programs (e.g., home- and community-based waiver services, state general-revenue-funded programs, and Medicare long-term care services) are consolidated into the single Family Care program, and CMOs are paid a capitated rate. This creates an incentive for the CMOs to provide support to enrollees in their homes rather than in institutions. The program also allows enrollees to have a high level of self-direction, organizing services around enrollees’ unique needs and preferences rather than strictly by allowable services or designated providers. Through its focus on social outcomes, the program has succeeded in increasing choice and access and improving quality, but early results found no effect on claims-based measures, such as utilization, and it was not possible to determine the cost-effectiveness of the program (Alecxih et al., 2003). Regardless, enrollees did not experience a decline in service levels at the start of the program, and the demand for services from the centers has been much stronger than anticipated (Medstat, 2003). Cash and Counseling Under the national cash and counseling demonstration project con- ducted in three states, individuals received a monthly allowance (in the form of direct cash payments) to purchase disability-related goods and services. Enrollees were provided with counseling and financial assistance to help them plan and manage their choices. An evaluation found that the program improved satisfaction and the quality of life for enrollees and caregivers, re- duced most unmet needs among enrollees without adversely affecting health or safety, and resulted in a reduction in nursing-home and other long-term care costs (Foster et al., 2003; RWJF, 2006). Costs were somewhat higher for enrollees because they were receiving more of the care that they were authorized to receive. Similar programs are now being adopted in 12 more states, and federal waiver authority is no longer required for states to imple- ment cash and counseling programs. One unusual aspect of these efforts is that they often allow patients to hire informal caregivers as their workers. Critics suggest that this allow- ance presents an opportunity for fraud and abuse and worry that costs will soar if informal caregivers currently providing unpaid care start to demand payment for their services (Stone, 2000). Others contend that the allowance will expand the pool of available caregivers and that the services provided may be more in line with patients’ preferences (Benjamin, 2001). Evidence of the effect of hiring relatives is not clear. One study found that about one in five paid informal caregivers had not been providing care prior to the

NEW MODELS OF CARE 93 formal hiring. The study also found that beneficiaries had a greater sense of security and choice in hiring a family member. Overall, the results of the cash and counseling demonstration, which allowed enrollees to hire family, indicate that the project did not result in misuse of Medicaid funding. Features of Innovative Models The committee did not attempt to rank the models described above or to recommend one model of care over another. In fact, little evidence exists that one might use to rate the relative effectiveness of these different approaches. Typically, evaluations focus on whether a single model proved to be successful rather than identifying which of several models produced the strongest results. The committee concluded that no single one of the models described above would be sufficient to meet the needs of all older adults. Instead, a variety of models will need to be employed to meet the targeted needs of older adults. For example, preventive home visits may be too costly to expand to all older persons, the majority of whom may not even require that level of care. Similarly, caregiver-support programs may not be sufficient for older adults with more intensive needs. The health care needs of the older population are diverse, and addressing those needs will require varying models of care. Fortunately, the models described above have generally been successful in enrolling mainly those older adults who would best benefit from the expanded services. After reviewing the evidence on a number of different models of care, the committee concluded that some of the models with the strongest evi- dence of success in improving care quality, health-related outcomes, or efficiency have common features which may contribute to their success (Table 3-3). The model components described in Table 3-3 have shown positive outcomes, at least in some circumstances, but these findings need to be interpreted with caution. First, the list is derived from an examination of only those interventions that have been rigorously evaluated and published in the peer-reviewed literature; many others have not yet been thoroughly evaluated. Furthermore, because the models have proved successful in only certain settings, one cannot be certain that they will experience the same success if they are adopted more widely. Adoption of a model in rural areas or at community hospitals, for instance, may not yield the same results as when the initiatives were undertaken at urban academic medical centers. Similarly, there is limited information on the scalability of the models, that is, on whether they could be successfully applied to a much larger popula- tion of patients. Finally, the literature review commissioned by the com- mittee focused on identifying interventions that have produced successful results. In some cases, alternative evaluations of the same model may show

94 RETOOLING FOR AN AGING AMERICA TABLE 3-3  Features of New Models (Select Research Findings Showing Positive Results) Description Findings in Support of the Intervention Interdisciplinary team care.  Providers from Some studies demonstrated improved different disciplines collaboratively manage the survival and quality of life (QOL) care of a patient. These providers may include (improved well-being, less anxiety, and primary care physicians, registered nurses, dyspnea), quality of care, health outcome social workers, physical therapists, pharmacists, scores, and patient satisfaction. occupational therapists, recreational therapists, Some also showed lower total costs, dieticians, home-care providers, personal-care fewer hospital admissions, physician attendants, and drivers. The members of the visits, emergency department visits, and team communicate regularly with each other x-rays. about their patients. Care management.  In most forms a nurse or Studies examining care management for social worker provides patients (and sometimes patients with heart failure demonstrated families) a combination of health assessment, improved satisfaction, use of appropriate planning, education, behavioral counseling, medications, QOL, and survival, as well and coordination. Their communication with as fewer hospital admissions and days. primary care providers varies from frequent to rare, depending on the care-management program. Chronic disease self-management Improved QOL (psychosocial function, programs.  Self-management programs are control of symptoms, pain, stiffness), structured, time-limited interventions designed functional autonomy (e.g., mobility, to provide health information and to empower fewer bed days, walking capacity), and patients to assume an active role in managing satisfaction. their chronic conditions. Some are led by health Fewer hospital admissions and days, professionals and focus on the management lower coronary artery disease inpatient of specific conditions, such as stroke, while costs. others are led by trained laypersons and address chronic conditions more generally. Pharmaceutical management.  Advice about Improved quality of care (adherence medications is provided by pharmacists to to medication guidelines), QOL (fewer patients, either directly or through the actions of symptoms), control of blood pressure, interdisciplinary teams. Recommendations are and survival. intended to encourage the safe, effective use of Insufficient evidence to indicate efficiency prescribed and over-the-counter medications. improvements. Preventive home visits.  Home visits are Improved QOL, survival, functional provided to older persons by nurses or other autonomy. visitors to monitor health and functional status Fewer nursing-home and hospital and to encourage self-care and appropriate use admissions. of health care services. These visitors usually visit their clients quarterly and communicate regularly with their patients’ primary care providers.

NEW MODELS OF CARE 95 TABLE 3-3  Continued Description Findings in Support of the Intervention Proactive rehabilitation.  As a supplement to Improved QOL (less pain, fewer primary care, rehabilitation therapists provide symptoms, decreased fear of falling, outpatient assessments and interventions improved self efficacy), functional designed to help disabled older persons to autonomy (improved activities of daily maximize their functional autonomy, home living [ADLs] and instrumental activities safety, and quality of life. Most of the few of daily living [IADLs], functional existing experimental programs operate in independence, chance of remaining at concert with patients’ primary care physicians. home), and survival. Insufficient evidence to indicate efficiency improvements. Caregiver education and support.  These Improved QOL (e.g., mood) and physical programs are designed to help the informal functioning of care recipients. caregivers of older persons with chronic Lower total cost of care, delayed and conditions such as dementia and stroke. Led by fewer nursing home admissions. psychologists, social workers, or rehabilitation therapists, these programs provide varying combinations of health information, training, access to professional and community resources, emotional support, counseling, and coping strategies. They communicate with primary care providers primarily through their clients. Transitional care.  Typically a nurse or an Improved QOL and survival. advanced-practice nurse prepares and coaches Lower total costs, fewer hospital the patient and informal caregiver for the readmissions. transition from hospital to home. The nurse visits the patient at home to ensure that all needed medication, equipment, and supplies are available and that the patient and caregiver know how to use them, how to self-monitor, and whom to call if problems arise. The nurse continues to monitor the situation for several weeks until the patient has returned to pre- admission status, contacting the primary care physician as needed. SOURCE: Boult et al., 2007. no improvement in quality, outcomes, or efficiency. Still, the results from these evaluations give reason to be cautiously optimistic that the diffusion of models with these features could result in improved care for older adults and perhaps introduce greater efficiencies into the Medicare and Medicaid programs.

96 RETOOLING FOR AN AGING AMERICA PAYING FOR NEW MODELS OF CARE The models of care with the strongest evidence base often expand the range of services provided to older patients, for example, with the addition of social services, caregiver education and support, and preventive home visits. Yet, Medicare typically does not cover these additional services, even if evaluations indicate that they reduce costly hospitalizations or nursing- home use in the long run. This lack of coverage contributes to the failure of many models to gain widespread traction. This section reviews the way in which Medicare services are currently paid for and presents several alterna- tives that could be used to foster the development and implementation of new models of care. Fee-for-Service Medicare One major problem is that brief visits are a poor way of managing chronic conditions even though care for chronic conditions is the most com- mon reason that Medicare patients seek physician care (Hing et al., 2006; McGlynn et al., 2003; Scherger, 2005). Furthermore, under the FFS system, more visits lead to higher physician and hospital revenues regardless of the quality or efficacy of the services being delivered (MedPAC, 2006). Payment is directed to individual physicians and emphasizes treatment for in-person care, which serves as a barrier to care coordination. This disincentive is particularly significant since most Medicare patients seek care from multiple providers (MedPAC, 2006). Furthermore, such a payment mechanism pro- vides no financial incentive for health care providers to deliver services that extend beyond the typical office visit, such as ongoing patient education to teach older adults how to better manage their chronic conditions between visits (Brown et al., 2007). Medicare is required by statute to apply its rules uniformly to all providers, limiting its ability to reward exemplary performance (Berenson and Horvath, 2003). CMS cannot provide additional payment or greater flexibility to organizations that offer additional services to patients, even if they are targeting frail older adults or some other particularly needy group of older adults. Overall, the traditional FFS system limits innovation in care delivery. Shifting the focus of care delivery away from acute care is difficult in part because of the rather complicated process that CMS must follow in order to add coverage for newer services, such as preventive home visits or care coordination. CMS must determine that the service fits into a statuto- rily established benefit category and that it is “reasonable and necessary” in order to diagnose or treat an illness, and then it must assign the service an appropriate payment code. Many services that are critical components

NEW MODELS OF CARE 97 of new models of care would have difficulty fitting into these criteria. For example, neither patient education to promote self-management nor inter- disciplinary team meetings to discuss patients’ health status fit easily into a statutorily established benefit category (Berenson and Horvath, 2003). Fur- thermore, many geriatric care models require the services of care managers, typically nurses or social workers, but these workers often do not qualify for Medicare reimbursement. Statutory changes will be needed to make it possible to pay for these services. Medicare Advantage Nineteen percent of Medicare beneficiaries are enrolled in Medicare Advantage (MA), Medicare’s managed care program. MA’s capitated pay- ment system puts health plans at financial risk, which gives them an in- centive to identify high-risk enrollees and assist them in averting medical complications and also to promote continued good health among older beneficiaries who are not chronically ill. The goal of this approach is to encourage health plans to promote appropriate, cost-effective care across settings (Berenson and Horvath, 2003). Capitated payments allow for greater innovation in care delivery and can promote the adoption of new models of care. For example, Kaiser Permanente’s Medicare HMO has been able to hire greater numbers of geriatricians and increase payments for their services. In addition, MA plans offer benefits beyond those that are available in the traditional FFS system, including preventive dental services. Care coordination, which is generally not available to beneficiaries under FFS, is routinely offered by MA plans and is administratively easier to perform under capitation because of the plans’ provider networks. Plans are required to use any cost savings they re- alize to provide benefits beyond those required by the Medicare program. Studies indicate that older adults who choose to enroll in MA are gen- erally healthier and have lower medical costs than FFS beneficiaries, and at least one study suggests that the incentive for MA plans to maintain this member composition may persist despite the implementation of risk adjust- ment (MedPAC, 2007a). CMS began phasing in risk-adjustment payments in 2004, and by 2007 payments were based entirely on risk-adjusted rates (Berenson and Horvath, 2003). At the same time, CMS also included a hold-harmless adjustment so that plan payments would not decline due to risk adjustment. In fact, payments to MA plans are about 12 percent higher than the average FFS costs in the same area (Kaiser Family Foundation, 2007). That difference is expected to decrease as the hold-harmless adjust- ment is phased out through 2011 (MedPAC, 2007b). Although capitation appears to be a reasonable means to incorpo- rate cost-effective new models of care into practice, this promise has not

98 RETOOLING FOR AN AGING AMERICA been fully realized. Based on recent experience, health plans have typically contracted with all available physicians and hospitals rather than develop- ing tighter networks, and the quality of care for individuals with chronic disease in FFS and managed care has ended up being roughly equivalent (Norwalk, 2007). However, a review of studies conducted by Miller and Luft found that enrollees in Medicare HMOs reported worse results on measures of access to care and patient satisfaction (Miller and Luft, 2002). In short, considerable debate still exists about whether the added funds provided to MA plans have been worth the investment. New Financing Mechanisms Given the challenges associated with traditional FFS Medicare and MA, a new model of payment is needed to support effective models of care and the integration across various settings of service that are necessary to pre- vent or delay declines in functional and health status for older adults (Biles et al., 2006; Guterman and Serber, 2007). Even with start-up funding from a foundation, insurer, or provider organization, the long-term sustainability of such services is limited in the absence of appropriate reimbursement from Medicare and other payers. It is beyond the scope of this report to recommend a specific method of reimbursement to support new models of care, but the committee did identify several promising methods. In general, it is important to note that during the research and demonstration phase of a new model CMS typically sets up financial arrangements that differ significantly from the traditional FFS arrangement. In order to move from the demonstration stage to wide- spread adoption, the general financing system will also need to be altered, likely requiring that some sort of capitated arrangement be put in place. Special Needs Plans As a result of the Medicare Modernization Act (MMA) of 2003, special needs plans (SNPs) were created within the MA program. SNPs can target their enrollment to high-needs patients such as institutionalized beneficiaries, dually eligible beneficiaries, or beneficiaries with severe or dis- abling conditions (CMS, 2007c). Targeted enrollment allows plans to design clinical programs that can accommodate those with distinct health needs, which can potentially result in reduced hospitalization and institutionaliza- tion (CMS, 2007a). SNPs are paid under the same system (risk-adjusted capitation) and regulated in the same manner as other MA plans. The number of SNPs has been growing rapidly, increasing from 276   Medicare Modernization Act of 2003. Public Law 108-173. 108th Congress. (2003).

NEW MODELS OF CARE 99 in 2006 to 775 in 2008. As of November 2007, SNPs had enrolled more than 1 million Medicare beneficiaries (Harrison and Podulka, 2007). SNPs were reauthorized through the end of 2009, including a 1-year moratorium for new SNPs. To evaluate the effect of using SNPs, CMS contracted with the National Committee for Quality Assurance (NCQA) to develop SNP- specific measures based on those used for the Healthcare Effectiveness Data and Information Set (HEDIS). Measures specific to the care of older adults include glaucoma screening, osteoporosis management, and use of high-risk medication (NCQA, 2008). SNPs were required to report on these measures by June 30, 2008; data regarding the results of this evaluation were not available at the time this report was prepared. MedPAC Approaches A number of additional proposals to support new models of care have been developed. MedPAC proposed two approaches for enhancing care co- ordination in Medicare FFS (Stone, 2000). Under the first approach, group practices or integrated delivery systems would furnish care-coordination services to high-risk patients (e.g., a nurse care manager would share space with the physicians). These group practices would be responsible for invest- ing in information technology and in a nurse-manager infrastructure in or- der to better manage care. Under the second approach, solo or small group practices would refer high-risk patients to an affiliated care-management organization that would employ the care-manager nurses and have infor- mation systems to assess patient severity levels and target interventions. Medicare would pay the care-coordination entity (either the group practice or the care-management organization) for services, and that payment would be tied to cost savings and quality goals. Payment would be either shared savings or an at-risk care managed fee. Medicare would also provide an incentive payment to physicians to encourage them to collaborate with the care managers. Addition of Medicare Benefits Another way to support new models of care would be for Congress to create additional Medicare benefits. For example, one proposal calls for the creation of a modified home visit benefit for beneficiaries in need of extended home-nursing and personal-care services (Berenson and Horvath, 2003). The new, lower-level home health benefit would not be as intensive as the current home health benefit, but it could allow instead for physicians   Medicare, Medicaid, and SCHIP Extension Act of 2007. Public Law 110-173. 110th Congress. (2007).

100 RETOOLING FOR AN AGING AMERICA to authorize their nurses or physician assistants to periodically conduct home visits for patients unable to come into the office. It would cover such services as medical assessment, medical monitoring, and medication management. Delivery of such services would allow the physician to receive more direct knowledge than could be obtained if similar services were pro- vided through a separate home health agency. This approach of legislating additional benefits could potentially be applied to other types of services, such as chronic-disease self-management training and caregiver education and support. Advanced Medical Homes Finally, a more radical departure from the current FFS system is a proposal that calls for the creation of advanced medical homes through comprehensive payment for primary care (Goroll et al., 2007). In this system physicians would be paid a risk-adjusted, per-member, per-month fee that would cover care coordination and medical services provided to the patient (Berenson, 2007). Payment would be considerably higher than current FFS or MA payments, allowing practices a greater opportunity to support different models of care. Participating practices would be required to undergo structural and organizational changes (e.g., the adoption of interoperable electronic health records with decision support and the use of interdisciplinary teams) that follow established standards. A portion of the payment would then be based on performance. Risk adjustment would make it less likely that physicians would avoid high-risk or psychosocially disadvantaged patients and would also influ- ence the pay-for-performance goals (Goroll et al., 2007). Several validated diagnosis-based models of risk adjustment exist and have been modified for payments to health plans (Ash et al., 2000; Kronick et al., 2000; Newhouse et al., 1997). Those models would need to be further modified for the prac- tice level and need to include the spectrum of risk determinants, including patient behaviors. Although costs would initially be high, proponents of this revised payment system believe that long-term costs would be tempered by reductions in administrative costs, inefficiencies, and overutilization. This proposal differs from some capitated payment systems in that physicians would not be at risk for hospital, specialist, and ancillary service costs. Appropriate utilization of services would be achieved through the use of evidence-based guidelines and decision-support systems, and the pay-for- performance bonuses would be based both on outcomes and efficiency. If responsibility for a patient is transferred to a specialist—for example, in the case of a patient with cancer—the specialist may receive some or all of the per-member, per-month payment. Additional payments to practices under this proposal provide the means

NEW MODELS OF CARE 101 to offer new services or deliver care in a new manner (e.g., preventive home visits and use of interdisciplinary teams). It should be noted that CMS is implementing a new Medical Home demonstration program in 2008 that is similar in many ways to the ad- vanced medical home concept. According to the statutory language, phy- sicians will be required to (1) provide ongoing support, oversight, and guidance to implement an integrated, coherent, cross-discipline plan for ongoing medical care, which will be developed in partnership with the patient and all other physicians, medical personnel, and agencies (e.g., home health agencies) providing care to the patient; (2) use evidence-based medicine and clinical decision support tools to guide decision making; (3) use health information technology (e.g., remote monitoring and patient registries) to monitor and track the health status of patients and to provide them with enhanced and convenient access to services; and (4) encourage patients to engage in the management of their own health through educa- tion and support systems (CMS, 2008b). Participating physicians will be reimbursed under the traditional Medicare Physician Fee Schedule but will also be eligible for a care-management fee for each participating beneficiary under their care and a bonus based on the achievement of savings and qual- ity goals (ACP, 2006). However, while the concept of an advanced medical home was intended to be applicable to all individuals, the demonstration project will be limited to those with multiple chronic illnesses. DISSEMINATION OF NEW MODELS OF CARE Identifying successful models of care is just the first challenge in im- proving the delivery of services to older adults. Successful models need to be replicated and incorporated widely into practice in order to reach a large patient population, and, in general, the adoption of best practices has occurred very slowly in the health care sector as well as other industries (Berwick, 2003). Indeed, evidence shows that innovations that have been demonstrated to improve the quality of patient care can take more than 17 years to become common practice (Balas and Boren, 2000). Little is known about the best way to promote the exchange of information concerning how to improve the quality of care (IOM, 2006a). Rogers’ diffusion of innovations theory defined five categories related to the adopters of new practices: • Innovators, who embrace new ideas • Early adopters, who are the opinion leaders of a community • Early majority, who are convinced by the early adopters to adopt the innovation

102 RETOOLING FOR AN AGING AMERICA • Late majority, who adopt the innovation mostly due to peer pressure • Laggards, who are skeptical and resistant to change This theory suggests that the adoption of new ideas by a select few will lead to a process of natural diffusion through which ideas spread throughout a community. Rogers also described how perceptions of the innovations can contribute to the adoption of a new practice. These per- ceptions include • relative advantage (comparison of the innovation to current practice); • compatibility (how the innovation fits with the adopter’s values, needs, etc.); • complexity (difficulty of adopting the innovation); • triability (if the innovation can be tested before full investment); and • observability (whether others have successfully adopted the innova- tion) (Rogers, 2003). Aside from these characteristics, a variety of other factors affect the adoption of new ideas, including both external factors (e.g., financial in- centives and politics) and internal factors (e.g., competing priorities and resources) (IOM, 2006a). Finally, successful adoption of innovations de- mands commitment and a readiness for change as well as the support of organizational leadership in the adopting institution. In the case of new models of care, dissemination has traditionally been slow and many models have been proved to be unsustainable (Leipzig et al., 2002; Reuben, 2002; Wolff and Boult, 2005). According to Rogers’s theory, a number of factors, if present, can be expected to improve the perception and potential appeal of new models of care for older patients. They include • the model having an intuitive appeal; • the existence of a strong evidence base demonstrating benefits for patients; • potential cost savings; • patient dissatisfaction with existing care; and • secular trends, such as the aging of the population, recognition of the importance of managing chronic disease, and the move toward community-based care (Leff, 2007; Rogers, 2003).

NEW MODELS OF CARE 103 A number of factors can also diminish the potential appeal of new models. They include • information gaps in the literature that leave potential adopters with insufficient detail about the model, including a lack of information about such things as the optimal target population, staffing require- ments, and the training and supervision necessary for staff; • an evidence base that focuses on patient-related outcomes but not on other outcomes relevant to adopting organizations; • the existence of few or no financial incentives or even of signifi- cant short-term financial disincentives, such as substantial startup costs; • lack of awareness by patients and families of the potential personal value of these models; • reliance on teams of providers, which makes the models complex and difficult to implement; • riskiness caused by the model having been implemented and ob- served in only a few other locations; and • poor alignment with the circumstances of a potential adopter’s lo- cal health system (Frank et al., 2003). Experiences with Individual Models of Care While the published literature on the dissemination challenges associ- ated with the adoption of specific models of care for older adults is generally limited, some information is available on the dissemination experiences of the IMPACT and PACE models (described above) as well as on the Hospital Elder Life Program (HELP), a model of care designed to prevent delirium and functional decline in hospitalized older adults (Inouye et al., 2006). Experience from the IMPACT Model The IMPACT model for depression treatment was originally imple- mented between 1999 and 2001 in 18 clinics nationwide; by 2007, 67 individuals or organizations had implemented or were pursuing IMPACT or key components of the program (IMPACT Implementation Center, 2007). The spread of the IMPACT model, though somewhat limited, has been aided by the IMPACT Implementation Center, which is funded by private foundations and provides resources and technical assistance to organiza- tions seeking to adopt the IMPACT model. Although it has not been widely adopted, IMPACT has served as a foundation for the creation of other models, such as the Prevention of Suicide in Primary Care Elderly: Collaborative Trial (PROSPECT), spon-

104 RETOOLING FOR AN AGING AMERICA sored by the National Institute of Mental Health (Bruce et al., 2004). Like IMPACT, PROSPECT provides depression-care management to older pa- tients in primary-care settings in an effort to reduce the burden of depressive symptoms, remove suicidal ideation, and improve health-related quality of life. Twenty practices in New York, Philadelphia, and Pittsburgh provided a total of 598 participants with either treatment as usual or depression care management similar to that employed in IMPACT. An evaluation of PROSPECT in a 53-month follow up found that the program resulted in significantly better response and remission rates for major depression, faster resolution of suicidal ideation, and reduced mortality. Despite the effectiveness of models that provide depression treatment in primary care settings, financial and organizational barriers have made the interventions difficult to sustain in clinical practice (Barry and Frank, 2006; Frank et al., 2003; Pincus et al., 2003). The cost of providing IMPACT care for one individual is approximately $580 per year (Bachman et al., 2006), but capitated payment creates an incentive for primary care physicians to deliver fewer services, not more. Further, additional payment (under FFS or capitation) is not available for the use of depression-care managers in the primary care setting. Behavioral health carve-outs also serve to reinforce the disincentives to treat depression in the primary care setting. Carve-outs allow primary care physicians to refer patients for specialized care without penalty, and they preclude the physician from billing for mental health procedures. The higher co-payments charged to patients receiving mental health care services also discourage utilization. These factors all serve as barriers to the adoption of models such as IMPACT or PROSPECT, even if care in the primary care setting is cost-effective or most appropriate for patients. Furthermore, physician education and training does not always pro- mote or encourage depression care in the primary care setting (Pincus et al., 2003). Behavioral health training is limited and highly variable in both family medicine and general internal medicine, and it is not made clear during physician training whether primary care providers are responsible for providing behavioral health services. Primary care providers may view diagnostic systems as too complex to implement (Pincus et al., 2003) and may feel little pressure to implement depression care models in the absence of demand from patients or payers. Eliminating the current disparities in mental health copayments would be one way to increase patient demand. Experience of the PACE Model The initial success of the PACE approach led Congress in 1997 to designate PACE as a permanent Medicare provider and to give state Med- icaid agencies the option to include PACE as a Medicaid benefit (Degruy,

NEW MODELS OF CARE 105 1996). By 2004 Congress had authorized 180 PACE programs, but while approximately 3 million older adults were eligible for PACE in that year, only about 10,000 were being served by a PACE program. Currently 42 PACE programs are operating in 22 states (National PACE Association, 2007). Overall, the growth of PACE has not met expectations. The initial PACE programs received significant start-up funding from private foundations, allowing the development of many independent, free- standing programs (Gross et al., 2004). But once grant funds became unavailable, only large health care organizations, such as hospitals, health care systems, and long-term care systems, had the funds to make the initial investment. Securing facilities and staffing for the programs requires signifi- cant capital expenditures (Gross et al., 2004). Organizations attempting to set up a PACE program may also have difficulty in collecting an adequate patient base because of geography (i.e., sparse populations in rural areas) or because of an insufficient number of adults in a community who qualify for the program. A further hurdle has been local labor shortages, particularly in nursing and therapies, which have made it difficult to fill open positions even when funding is available. On the other hand, the environment and regular hours offered by PACE programs have generally made it easier than it otherwise would have been to attract and retain staff. Marketing the programs has also been difficult in some cases. Many PACE programs operate in com- petitive, service-rich environments which offer a number of other service options for older adults. Moreover, PACE centers receive a combined capi- tated rate of approximately $4,900 per member per month from Medicare and Medicaid. For older adults who are not eligible for Medicaid, this cost is often prohibitively high (Hansen, 2007). The National PACE Association, largely funded by private foundations, offers a number of resources and technical assistance to organizations that wish to establish PACE programs. The association also awards grants to states to expand their capacity to administer PACE programs. In addition, Congress has appropriated funding to the Health Resources and Services Administration (HRSA) to support technical assistance and assess the staff- ing and training needs of rural providers in developing PACE programs. Experience of the Hospital Elder Life Program (HELP) As noted above, the HELP is a model of care designed to prevent de- lirium in hospitalized older adults. Delirium is defined as an acute decline in cognitive functioning and attention, and it is the most frequent complication of hospitalization in older persons, being estimated to occur in 14 percent to 56 percent of older hospitalized adults (Leslie et al., 2005). Delirium is also associated with increased morbidity, mortality, and health care costs.

106 RETOOLING FOR AN AGING AMERICA The HELP interdisciplinary team consists of a geriatric nurse-specialist, a specially trained “Elder Life Nurse Specialist,” a geriatrician, and trained volunteers. The Elder Life Nurse Specialist is the program and volunteer coordinator and is responsible for screening and enrolling patients, and keeping track of the program’s adherence to the HELP guidelines. The Elder Life Nurse Specialist has specialized training in geriatrics and carries out nursing-related assessments and intervention protocols targeted toward six delirium risk factors (cognitive impairment, sleep deprivation, immobility, visual impairment, hearing impairment, and dehydration) (Inouye et al., 2006). Evaluations of HELP indicate that it is effective in preventing de- lirium and functional decline, and that it is cost effective in hospitals and long-term care settings (Inouye et al., 2006). In 2000, a HELP Dissemination Program was established with funding from private foundations. A dissemination team (a full-time nurse practi- tioner, 10 percent time for the geriatrician who developed the program, and 25 percent time for a dissemination project director) provided training materials, offered ongoing support for HELP hospital staff implementing HELP, and held an annual conference for HELP sites. Additionally, a HELP website was created to make resources on HELP readily available to inter- ested organizations. Like IMPACT and PACE, dissemination of HELP has been modest. The dissemination team assisted 17 sites with the implementation of HELP, and several more sites have since adopted HELP. Through interviews with HELP staff at nine sites, researchers identified six challenges associated with implementation of the program: (1) gaining internal support for the pro- gram despite differing requirements and goals of administration and clinical staff, (2) ensuring effective clinician leadership, (3) integrating with existing geriatric programs, (4) balancing program fidelity with hospital-specific circumstances, (5) documenting positive outcomes of the program despite limited resources for data collection and analysis, and (6) maintaining the momentum of implementation in the face of unrealistic time frames and limited resources (Bradley et al., 2004a). A second study was conducted to identify key elements that make it easier to sustain the program. The researchers identified three factors: the presence of clinical leadership, the ability and willingness to adapt the original HELP protocols to local hos- pital circumstances and constraints, and the ability to obtain longer-term resources and funding for HELP (Bradley et al., 2005). Like many other models, HELP requires the delivery of additional clinical services that are not typically reimbursed under Medicare, and the diffusion of HELP has largely depended upon staff funded specifically to disseminate the program (Bradley et al., 2004b).

NEW MODELS OF CARE 107 Fostering the Dissemination of New Models of Care One of the major challenges to the adoption of a new model is that it can require collaboration among a variety of stakeholders, including public and private insurers, health systems and hospitals, health care regulators, and practicing professionals. Much of the research on the dissemination of innovations has focused on physicians, with little consideration for the role of other workers. The Medicare payment system itself presents many barri- ers, including the focus on provider-specific reimbursement, the limitations on who can bill for services, and the complex regulatory environment that makes legislative changes difficult. Additionally, the health care workforce may lack sufficient numbers of providers to fully staff these models. Contextual factors, such as the challenges in changing the cultures of health care organizations and gaining internal support for adoption from the organization’s leadership, are also critical to dissemination, but such factors are not well understood. Creating culture change in health care settings requires that organizations and individuals consider better ways to deliver care, including changing the ways that health care personnel func- tion (Shields, 2005). Additionally, when implementing new models, health care organizations need to become effective learning organizations. That is, they need to be able to learn from their experiences and change course as a result of that learning. In 1990 Senge defined the characteristics of success- ful learning organizations (Senge, 1990). They include • systems thinking (determination of how individual parts of the system interact); • personal mastery (recognition by the individual of his or her role in the system); • mental models (examination of individual perceptions and willing- ness to change); • shared vision (development of a common goal); and • team learning (enhancement of individual capabilities to achieve the shared vision). These learning organizations need strong leaders who are committed to changing the system, ongoing dialogue among all members of the sys- tem, and a commitment to continuous quality improvement, including the ability to learn from mistakes (IOM, 2007). In addition to dealing with institutional resistance to culture change, health care organizations that are attempting to change their vision of how care is delivered needs to take into account public perceptions of the use of alternative models and also the types of workers they need to carry out that vision. While some models are difficult to diffuse because of their inherent

108 RETOOLING FOR AN AGING AMERICA design, others may be hard to diffuse because of administrative or financial barriers. The committee concluded that innovative models of care for older pa- tients generally fall into the latter category—models that are difficult to diffuse because of administrative or financial barriers—and that these administrative and financial barriers should be addressed. Recommendation 3-1:  Payers should promote and reward the dissemi- nation of those models of care for older adults that have been shown to be effective and efficient. Incentives to adopt new models of care should include enhanced pay- ments for services under these models; provision of capital for infrastructure, such as health information technology; the streamlining of administrative and regulatory requirements; and the elimination of existing impediments to the use of innovative models by older patients, such as Medicare’s copay- ment disparity for mental health and other services. DEVELOPMENT OF FUTURE MODELS AND FURTHER RESEARCH The committee’s commissioned review of models of care revealed sev- eral types of models that hold promise for providing high-quality and cost- effective care for older adults at several points along the care continuum. The committee supports the continued development of models in these areas. Still, as discussed previously, the evidence base on models of care for older adults remains somewhat limited, and the information regarding which models are most suitable for dissemination needs to be improved. Considering the current relative lack of investment in research and dem- onstration programs for new models of care, especially in comparison to annual spending on health care services, much more funding is needed to develop this evidence base. In particular, efforts should target those areas of care that demonstration programs have traditionally overlooked and should look for the most efficient ways to use the workforce in staffing new models of care. Recommendation 3-2:  Congress and foundations should significantly increase support for research and demonstration programs that • promote the development of new models of care for older adults in areas where few models are currently being tested, such as prevention, long-term care, and palliative care; and • promote the effective use of the workforce to care for older adults.

NEW MODELS OF CARE 109 Relatively few models of care focus on improving the rates of utiliza- tion of preventive clinical services among older adults or address behavioral health risks, such as exercise, smoking, and weight management. This may be due in part to a misconception that older adults are too old to benefit from prevention efforts (Hansen, 2007; The John A. Hartford Foundation, 2000). In reality, however, about one-fifth of older adults have no chronic illness and are generally in very good health; models should be explored that can promote the continuation of good health for this group. Models of long-term care appropriate for middle-class older adults should also be explored further. Many of the models tested to date have focused on dually eligible older adults and have relied upon the integra- tion of Medicare and Medicaid financing. The median household income of older adults is approximately $28,000 per year, however, which is well above the eligibility threshold for Medicaid (Fleming, 2002). Models of palliative care offer another example of where more research is needed. About half of families report concerns about the care provided at the end of life, particularly about the patient not receiving enough emo- tional support (DeNavas-Walt et al., 2007). End-of-life care varies consider- ably by race and ethnicity and by where a patient receives the care (Teno et al., 2004). More information is needed on the best way to improve the access to and the quality of palliative and end-of-life care. It is important to note, however, that these three areas—preventive ser- vices, long-term care for middle-class older adults, and palliative care—are meant only as examples of the types of models that warrant development and are not meant as an exhaustive list. There are other areas where few models are currently being tested that also deserve attention. Any such new models of care need to be tested for their appropriate- ness and effectiveness for special populations, such as low-income groups, racial and ethnic minorities, rural populations, and gay, lesbian, bisexual, and transgender groups. Older adults are a diverse group, with differences in language proficiencies, risks for diseases, education, acculturation, in- come, and family systems (e.g., dependency on adult children), all of which may affect their health and access to appropriate care. Models need to be developed that benefit diverse groups of patients. Not only is more information needed on efficient and effective models of care, but more research is needed to determine how best to create an effective workforce. Best practices need to be developed for increasing the size of the health care workforce (e.g., through improved recruitment and retention) and expanding its capabilities (e.g., through advanced education and training). More information is needed on how the size and capabili- ties of the health care workforce affect patient care in terms of quality and outcomes. If care continues to be provided in the same way, there will simply not be enough providers in the coming years to deliver the care that

110 RETOOLING FOR AN AGING AMERICA is needed. Therefore, new research and demonstration projects should be developed to test alternative approaches that advance the use of the health care workforce, including • programs to retain direct-care workers in nursing-home and home- care settings; • models of recruiting older volunteers to help care for older persons; and • financial incentives to increase the availability of informal caregivers. The challenges associated with caring for an aging society are not unique to the United States. Most other countries around the world are also experiencing increased demand for health care and social services due to increases in elderly and disabled populations (WHO, 2003). Many have been struggling with same issues of how to improve quality, organization, and resources for such care (Kodner, 2004). While some have successfully managed to address these issues, it is difficult to draw from the experiences of other countries given the very different nature of each health system’s organizational and financial structures. As the United States goes forward in developing new models of care, however, some lessons may be drawn from international efforts. Countries that have successfully addressed these challenges have several common at- tributes associated with their efforts. Among them are administrative con- solidation (the reorganization of key functions, such as client assessment, care planning, service coordination, quality management and financial oversight, into a single agency at the level closest to the target population), co-location of services (reducing service fragmentation by locating multiple elder care agencies in single service centers), and service-enriched housing (providing housing situations or physical environments that accommodate each patient’s individual health needs or preferences, allowing greater free- dom in choice of care settings). One specific lesson, for example, is the value of job delegation, which has been used successfully around the globe in various professions or populations, although not necessarily in situations related to the care of older adults. For instance, countries in Africa expanded their traditional workforce models in response to the HIV epidemic (Samb et al., 2007). In countries such as Malawi, where persons living with HIV/AIDS outnumber doctors 7,435 to 1 and nurses 286 to 1, the delegation of tasks has been essential to meeting care needs. Another example of job delegation is the way that countries such as Canada, New Zealand, Finland, and the United Kingdom developed auxiliary dental professions (e.g., an advanced dental

NEW MODELS OF CARE 111 hygienist or dental aide therapist) to solve overwhelming oral-health work- force shortages (Kravitz and Treasure, 2007). IMPLICATIONS FOR THE WORKFORCE As discussed previously, changing the way that health care services are delivered to older Americans will require an overall culture change by all segments of the workforce and delivery organizations, including changes in ideas about who needs to provide specific services and how those individuals need to interact with each other. Adopting new models of care will require the care teams to be flexible so that the workforce will be sufficient in both size and skill to meet the needs of older adults. While it is not possible to discuss in detail the implications of each individual model for the health care workforce for older adults, the committee de- termined that the models have certain common themes that demonstrate the need for the different segments of the health care workforce to adapt to changes in the way that care is delivered to older adults. The models that have the strongest bases of evidence typically require providers of different disciplines to work together to improve the coordi- nation of care. In addition, several of the models require providers to take on new roles and assume greater levels of responsibility. As more models depend on patients and informal caregivers being part of the health care team, these individuals will need to be given more education and training so that they can be more effective members of the team. Finally, as is true for the health care workforce as a whole, the development and use of new technologies will have implications for the health care workforce for older adults; the implications will arise not only from the need to train individuals in the use of these new technologies but also from their potential ability to assist existing health care workers in performing tasks and their potential for reducing the number of workers needed. These types of adaptations are discussed in general terms below and then in greater detail in subsequent chapters where their implications for different parts of the health care workforce are considered. New Roles and Responsibilities Many of the new models of care require the workforce to change its practices in various ways. For example, as discussed previously, the shah- bazim from the Green House model take on far more responsibility and are more involved in residents’ lives than are traditional CNAs. They interact regularly with the residents’ health care providers and alert them to changes in residents’ status. Under the IMPACT program, depression-care managers

112 RETOOLING FOR AN AGING AMERICA are responsible for the majority of patient care and monitoring (Sibbald and Roland, 1998). Many of these new roles and responsibilities require additional train- ing, although the training in some cases can be provided by the hiring organization and may not require a higher educational degree. IMPACT’s depression-care managers, for example, underwent a 2-day orientation session and 2-day training meetings (Wagner et al., 2001). Some models of care also require the professional providers to serve as the instructors to patients or informal caregivers. Overall, new models of care often require all members of the care team—whether they are health care professionals, formal direct-care work- ers, informal caregivers, or patients—to take on added responsibilities. Cascading various patient-care responsibilities—shifting them from one type of worker to another—will be an essential tool in efforts to alleviate the projected shortages in the numbers of providers available to meet the care needs of an aging society. In some cases, the assumption of these new responsibilities will require regulatory changes, most often through the expansion of state-based definitions of scopes of work. Recommendation 3-3:  Health care disciplines, state regulators, and employers should look to expand the roles of individuals who care for older adults with complex clinical needs at different levels of the health care system beyond the traditional scope of practice. Critical elements of this include • development of an evidence base that informs the establishment of new provider designations reflecting rising levels of responsi- bility and improved efficiency; • measurement of additional competence to attain these designa- tions; and • greater professional recognition and salary commensurate with these responsibilities. These new roles and responsibilities have implications for the work- force beyond the need for more training. First, as new and expanded roles are delineated, more will need to be done to assure the competence of those providing increased levels of care. Second, as more responsibilities are delegated by professionals to other members of the health care workforce, these professionals will have increased responsibility for management and supervision but will need to be taught the skills required for these roles. Finally, the assumption of increased responsibility, especially for direct-care workers, has been associated with greater job satisfaction, and ultimately,

NEW MODELS OF CARE 113 higher retention and potential improvement in patient outcomes. Specific examples of changing roles, delegation of responsibilities, and expanded scopes of work are discussed later in this report as they relate to each seg- ment of the workforce. Patients and Informal Caregivers Some models of care introduce new and expanded roles for patients and informal caregivers and integrate those individuals into the care team. An important element of the chronic-care model is engaging patients in their health and providing them with the education and tools to make decisions about their own care and to manage it (Arehart-Treichel, 2006; Unutzer et al., 2001). As more services are delivered in home- and community-based settings, patients and informal caregivers will become even more important to the delivery of care. And, as models of care recognize the contributions needed by these individuals to improve care, more will need to be done to educate and train them in principles of self-management, proper methods of service provision (e.g., wound care and medication administration), and use of new technologies. (See Chapter 6 for more on patients and informal caregivers.) Interdisciplinary Care The introduction of interdisciplinary teams into care delivery will pose a number of challenges. Although in the long run the use of such teams has the potential to reduce the use of intensive health services such as hospitalization, these teams are not adequately reimbursed at this time. Furthermore, since team care requires greater effort with respect to primary care and patient monitoring, the introduction of interdisciplinary teams to manage patients may strain the existing capacity of primary care providers even further. An additional challenge is that team training is not a focus of the curriculum for many providers, so that they may be unfamiliar with this practice style (see Chapter 4). Finally, effective teams also require a certain level of respect, comfort, and trust among members, which in some cases may not be present (Boult et al., 2001; Sommers et al., 2000). Care Coordination As discussed in Chapter 2, the coordination of care among provid- ers and across settings, especially during transitions, can greatly influence patient outcomes. Older adults often see multiple providers—on average, Medicare beneficiaries are treated by five physicians annually, and beneficia-

114 RETOOLING FOR AN AGING AMERICA ries with chronic conditions (e.g., heart failure, coronary artery disease, or diabetes) see an average of 13 physicians annually (IOM, 2007). As a result, the care that these beneficiaries receive from physicians and other health care providers is often fragmented and not well coordinated. The lack of coordination stems from a variety of factors, including poor definitions of accountability, misaligned financial incentives (including the inability to reimburse for care coordination under FFS), lack of connection among information systems, and minimal training of providers in cross-site col- laboration (Coleman, 2003; Coleman and Berenson, 2004; IOM, 2006b). In the 2007 IOM report Rewarding Provider Performance, the committee recommended that Medicare, in order to reduce fragmentation of services, encourage beneficiaries to identify a primary accountable source of care to act as that patient’s care coordinator and guide the patient through the health care (IOM, 2007). Many new models of care strive to improve care coordination, and these efforts can affect the use and development of the health care work- force. Some models, for example, require a geriatric care manager who helps patients navigate the health care system (see Chapter 4). Addition- ally, many efforts to improve care coordination call for enhancing com- munication among providers; this enhancement of communication among providers—and also between caregivers and patients—will require provid- ers to change their practice patterns in a variety of ways. Furthermore, as patients and their families assume more responsibility in care delivery, it will be essential to involve these individuals in the coordination of care, which in turn will make it necessary to recognize the barriers to effec- tive communication that some older adults experience, including hearing and vision deficiencies. (See next section for more on self-management.) Finally, one of the easiest ways to improve the coordination of care will be to enhance the use of those information technologies that help to share important patient information. Health Technology Many models of care require an increased use of health information technology (HIT), such as electronic health records and personal health records, to facilitate the sharing of information among providers and to improve their ability to coordinate the complex care of older patients. Health information technologies may also be used to build databases on the health of older populations which may be very useful to practitioners and researchers in aging. Other technologies used in new models may reduce the need for certain types of workers. For example, remote-monitoring tech- nologies can extend the reach of health care professionals into the home.

NEW MODELS OF CARE 115 As a result, many members of the health care workforce will need to be trained in the proper use of all of these technologies. Technologies that assist in performing activities of daily living may reduce the demands placed on direct-care workers and informal caregiv- ers, effectively shifting these responsibilities back to the patient’s level. The interaction between developing technologies and the health care workforce is discussed further in later chapters, and recommendations are offered for encouraging the development and use of health technologies. CONCLUSION Simply expanding the size of the workforce qualified to provide the needed health care services to older adults will not be sufficient to address the challenge that will face this country over the next two decades. It will be necessary to develop new models of financing and care delivery in order to promote greater efficiencies in the use of the existing workforce while at the same time promoting improvements in care quality. Although a number of innovative models have already been developed, few have been widely adopted, and in large part this is because no adequate financing mechanism is in place to encourage the promotion of these models. Given that no single model of care will be sufficient to meet the needs of all older adults in all settings of care across the health care continuum, the committee recom- mends both an improved dissemination of models that have been shown to be effective and the development of new models of care that address specific settings or populations that have largely been overlooked and that encourage more effective use of the health care workforce. The adaptation of these new models of care will have important im- plications for the development of a better health care workforce for older adults. Common features of new models include expanding the roles of workers (including expansion of the involvement of patients and their families), creating new provider roles, using interdisciplinary care teams, and improving the coordination of care through improvements in commu- nication. Today’s health care workforce is not properly prepared to perform its work in the ways that these new models demand, so all segments of the health care workforce will need to be educated and trained in the new care principles that underlie these models. The remainder of this report discusses the education, training, recruitment, and retention of the various segments of the health care workforce, with a particular emphasis on how the roles of health care providers will need to change in order to provide high-quality and cost-effective care to older Americans.

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As the first of the nation's 78 million baby boomers begin reaching age 65 in 2011, they will face a health care workforce that is too small and woefully unprepared to meet their specific health needs.

Retooling for an Aging America calls for bold initiatives starting immediately to train all health care providers in the basics of geriatric care and to prepare family members and other informal caregivers, who currently receive little or no training in how to tend to their aging loved ones. The book also recommends that Medicare, Medicaid, and other health plans pay higher rates to boost recruitment and retention of geriatric specialists and care aides.

Educators and health professional groups can use Retooling for an Aging America to institute or increase formal education and training in geriatrics. Consumer groups can use the book to advocate for improving the care for older adults. Health care professional and occupational groups can use it to improve the quality of health care jobs.

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